One of the most hated surprise medical bills is now gone after NH governor signs bill

Patients no longer owe the difference

New Hampshire made it illegal for ambulance companies to send patients surprise bills.

Senate Bill 245 took effect Jan. 1, 2026, and it bars a practice called balance billing, where an ambulance ride costs more than an insurer will pay and the company charges the patient the leftover amount.

Now, patients only owe their standard copays, coinsurance, and deductibles. Gov. Kelly Ayotte signed the bipartisan bill on July 31, 2025.

New Hampshire leads New England on this

No other state in New England had tackled this problem before. New Hampshire joins about 20 other states that passed similar protections in recent years.

The reason so many states had to act on their own comes down to a gap in federal law.

The No Surprises Act, passed in 2020, shields patients from surprise bills in many medical settings, but it specifically leaves out ground ambulances.

That gap pushed states to fill in the missing coverage themselves.

Insurers must pay 325% of Medicare

The law sets a specific reimbursement rate: insurers must pay ambulance providers 325% of the federal Medicare rate. But that number is temporary, lasting only two years through the end of 2027.

Medicare rates also vary depending on whether an area counts as urban, rural, or super rural, so the actual dollar amount shifts by location.

After the two-year window closes, the state Insurance Department will set a permanent rate based on a new cost study.

Two competing bills led to a deal

The final law came together from two separate proposals. Democratic Sen. Suzanne Prentiss of West Lebanon sponsored SB 245 with the 325% rate.

Meanwhile, Republican Rep. John Hunt of Rindge backed a competing bill, HB 316, that proposed a lower rate of 202%.

That figure came from a 2024 cost study by the Public Consulting Group, commissioned by the Insurance Department. Ambulance providers pushed back hard against the lower rate, saying it would not cover their costs.

Both sides made concessions

The compromise gave ambulance providers the higher 325% rate but only for two years instead of permanently.

Lawmakers also added a monitoring commission from Hunt’s bill to keep watch over the system during the transition.

Hunt accepted the higher rate as the cost of ending balance billing, though he called it well above what providers actually needed.

Prentiss called the deal a success, saying it came from all parties sitting down together.

Two ambulance services already shut down

The law arrived against a grim backdrop. Two ambulance services closed in New Hampshire in 2025 alone.

Berlin EMS shut down in April, forcing the city’s fire department to take over emergency medical runs.

Then the Warren-Wentworth Ambulance Service closed without warning on July 9 after every remaining staff member resigned.

The New Hampshire Ambulance Association had warned back in 2023 that EMS across the state faced a “state of emergency” due to staffing and money shortfalls.

Medicare and Medicaid drive the squeeze

The financial pressure on ambulance providers starts with who they serve. About 80% of all ambulance trips in New Hampshire involve a patient on Medicare or Medicaid.

Medicare covers only about 46% of the actual cost of an ambulance transport, and Medicaid covers roughly 42%.

Providers say they counted on higher payments from private insurers to close the gap, but those payments often fell short too.

Rural areas got hit hardest, with fewer residents, less tax revenue, and longer distances between calls.

State hired RAND for a new study

New Hampshire contracted the RAND Corporation to conduct a new cost study at a price tag of about $400,000.

The study will look at the real costs of running ambulance services and factor in inflation and current market conditions.

Providers had criticized the earlier 2024 study, saying it moved too fast and relied on data that did not reflect post-pandemic costs. The results will shape the permanent reimbursement rate that takes effect after 2027.

Patients get clear protections now

Anyone with a state-regulated private insurance plan will no longer face a surprise bill after an ambulance ride. Out-of-pocket costs max out at whatever their plan requires for in-network services.

The law covers both emergency 911 calls and non-emergency ground ambulance transport.

And ambulance providers cannot ask patients to sign away their balance billing protections, so the coverage sticks no matter what.

Some plans fall outside the law

The new protections have limits. Self-funded employer health plans, known as ERISA plans, fall under federal rules, so the state law does not cover them.

A large share of American workers get insurance through these kinds of plans. Air ambulance services also sit outside the law, since separate federal rules govern those.

The New Hampshire Insurance Department estimated the law could raise commercial insurance premiums by about 0.5%, or roughly $15 million total statewide.

The temporary rate runs through 2027

The 325% reimbursement rate stays in place through Dec. 31, 2027. The RAND Corporation study will produce findings that shape whatever permanent rate comes next.

A monitoring commission created by the law will track how the new system performs during the two-year transition.

Meanwhile, several other states are looking at similar ambulance billing protections in their 2026 legislative sessions, so New Hampshire’s approach could become a model.

The federal gap leaves millions exposed

About half of all emergency ambulance rides by privately insured patients could lead to a surprise bill, according to research from the Peterson-KFF Health System Tracker.

The average surprise ambulance bill runs about $450, but some reach into the thousands. Roughly 3 million privately insured Americans ride an ambulance to an emergency room each year.

Until Congress adds ground ambulances to the federal No Surprises Act, coverage will stay a patchwork that varies state by state.

This article was created with AI assistance and human editing.

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